Type B aortic dissection and thoracoabdominal aneurysm formation after endoluminal stent repair of abdominal aortic aneurysm.
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Endoluminal stent graft repair of abdominal and thoracic aortic aneurysms is being performed in increasing numbers. The long-term benefits of this technology remain to be seen. Reports have begun to appear regarding complications of stent graft application, such as renal failure, intestinal infarction, distal embolization, and rupture. Many of these complications have been associated with a fatal outcome. We describe a case of acute, retrograde, type B aortic dissection after application of an endoluminal stent graft for an asymptomatic infrarenal abdominal aortic aneurysm. An extent I thoracoabdominal aortic aneurysm subsequently developed and was successfully repaired. Aggressive evaluation of new back pain after such a procedure is warranted. Further analysis of the short-term complications and long-term outcome of this new technology is indicated before universal application can be recommended. (+info)
Effectiveness of clopidogrel and aspirin versus ticlopidine and aspirin in preventing stent thrombosis after coronary stent implantation.
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BACKGROUND: Ticlopidine has been shown to reduce the incidence of stent thrombosis compared with warfarin, but it may cause serious hematological side effects. Clopidogrel, a new thienopyridine derivative, may be a safe alternative to ticlopidine. The aim of this study was to compare the safety and efficacy of clopidogrel and aspirin with those of ticlopidine and aspirin in patients undergoing coronary stent implantation. METHODS AND RESULTS: The population of this study consisted of 2 groups: patients who underwent coronary stenting and were treated with ticlopidine and aspirin (TA group, n=1406), and patients who underwent coronary stenting followed by treatment with clopidogrel and aspirin (CA group, n=283). At 1-month follow-up, there was no difference in stent thrombosis (1.5% versus 1.4%, P=1.0) or major adverse cardiac events (3.1% versus 2.4%, P=0. 85) between the TA and CA groups, respectively. The probability of any side effect (neutropenia, diarrhea, rash) was significantly higher in the TA group (10.6% versus 5.3%, P=0.006; relative risk, 0. 53; CI, 0.32 to 0.86). CONCLUSIONS: These data suggest that clopidogrel may be an effective pharmacological regimen after coronary stent implantation. Furthermore, the simpler dosing regimen, the absence of neutropenia, and the lower frequency of other side effects make it a safe alternative to ticlopidine. (+info)
Management of renovascular disease: a review of renal artery stenting in ten studies.
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To evaluate the efficacy and safety of renal artery stents in renovascular disease, we identified 10 descriptive studies containing sufficient information for systematic evaluation. No randomized comparisons of stenting with angioplasty or with surgery were found. Overall, stents were placed in 416 renal arteries in 379 patients, mean age 64 years (range 27-84), 56% male. Of the stenoses, 97% were atheromatous (inter-study range 71-100%), 80% ostial (22-100%) and 31% bilateral (12-87%). The clinical indication for stenting was usually hypertension with or without mild renal impairment. Radiological indications for stenting were: narrowing of > or = 50% (in 9/10 studies) as a result of elastic recoil (58%) or dissection (2%) at the time of angioplasty; restenosis some time after angioplasty (15%); or as a primary procedure (25%). Technical success was reported in 96-100% of procedures. Restenosis (> or = 50% narrowing), evaluated in 312/416 (75%) arteries, generally between 6 and 12 months, was 16% overall. Hypertension was cured by stenting (DBP < or = 90 mmHg on no treatment) in 34/379 (9%) overall and in 34/207 (16%) of those whose renal function was normal initially. Six of 379 (1.6%) patients died within 30 days of stenting, but in only two (0.5%) was death judged to be procedure-related. Complications, other than those which led to dialysis, occurred in 42/379 (13%) patients, one third requiring intervention, ranging from blood transfusion to a surgical bypass procedure. Renal function as judged by serum creatinine concentration (SCC) improved in 26%, stabilized in 48% and deteriorated in 26% of patients whose renal function was impaired initially (SCC > 133 mumol/l). In one study, with average baseline SCC > 200 mumol/l, successful stenting slowed the rate of progression of renal failure when renal function was deteriorating beforehand. Nine of 379 (2.4%) patients, including 7/14 (50%) whose SCC was > or = 400 mumol/l initially, required dialysis after stenting. Stenting should be offered by specialist centres as a secondary procedure for unsuccessful angioplasty, or restenosis following angioplasty, to patients with renovascular disease and uncontrolled hypertension, advancing renal failure or pulmonary oedema. (+info)
Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.
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BACKGROUND: The treatment of thoracic aortic dissection is guided by prognostic and anatomical information. Proximal dissection requires surgery, but the appropriate treatment of distal thoracic aortic dissection has not been determined, because surgery has failed to improve the prognosis. METHODS: We prospectively evaluated the safety and efficacy of elective transluminal endovascular stent-graft insertion in 12 consecutive patients with descending (type B) aortic dissection and compared the results with surgery in 12 matched controls. In all 24 patients, aortic dissection was diagnosed by magnetic resonance angiography. In each group, the dissection involved the aortic arch in 3 patients and the descending thoracic aorta in all 12 patients. With the patient under general anesthesia, either surgical resection was undertaken or a custom-designed endovascular stent-graft was placed by unilateral arteriotomy. RESULTS: Stent-graft placement resulted in no morbidity or mortality, whereas surgery for type B dissection was associated with four deaths (33 percent, P=0.09) and five serious adverse events (42 percent, P=0.04) within 12 months. Transluminal placement of the stent-graft prosthesis was successful in all patients, with no leakage; full expansion of the stents was ensured by balloon inflation at 2 to 3 atm. Sealing of the entry tear was monitored during the procedure by transesophageal ultrasonography and angiography, and thrombosis of the false lumen was confirmed in all 12 patients after a mean of three months by magnetic resonance imaging. There were no deaths or instances of paraplegia, stroke, embolization, side-branch occlusion, or infection in the stent-graft group; nine patients had postimplantation syndrome, with transient elevation of C-reactive protein levels and body temperature plus mild leukocytosis. All the patients who received stent-grafts recovered, as did seven patients who underwent surgery for type B dissection (58 percent) (P=0.04). CONCLUSIONS: These preliminary observations suggest that elective, nonsurgical insertion of an endovascular stent-graft is safe and efficacious in selected patients who have thoracic aortic dissection and for whom surgery is indicated. Endoluminal repair may be useful for interventional reconstruction of thoracic aortic dissection. (+info)
Endovascular stent-graft placement for the treatment of acute aortic dissection.
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BACKGROUND: The standard treatment for acute aortic dissection is either surgical or medical therapy, depending on the morphologic features of the lesion and any associated complications. Irrespective of the form of treatment, the associated mortality and morbidity are considerable. METHODS: We studied the placement of endovascular stent-grafts across the primary entry tear for the management of acute aortic dissection originating in the descending thoracic aorta. We evaluated the feasibility, safety, and effectiveness of transluminal stent-graft placement over the entry tear in 4 patients with acute type A aortic dissections (which involve the ascending aorta) and 15 patients with acute type B aortic dissections (which are confined to the descending aorta). Dissections involved aortic branches in 14 of the 19 patients (74 percent), and symptomatic compromise of multiple branch vessels was observed in 7 patients (37 percent). The stent-grafts were made of self-expanding stainless-steel covered with woven polyester or polytetrafluoroethylene material. RESULTS: Placement of endovascular stent-grafts across the primary entry tears was technically successful in all 19 patients. Complete thrombosis of the thoracic aortic false lumen was achieved in 15 patients (79 percent), and partial thrombosis was achieved in 4 (21 percent). Revascularization of ischemic branch vessels, with subsequent relief of corresponding symptoms, occurred in 76 percent of the obstructed branches. Three of the 19 patients died within 30 days, for an early mortality rate of 16 percent (95 percent confidence interval, 0 to 32 percent). There were no deaths and no instances of aneurysm or aortic rupture during the subsequent average follow-up period of 13 months. CONCLUSIONS: These initial results suggest that stent-graft coverage of the primary entry tear may be a promising new treatment for selected patients with acute aortic dissection. This technique requires further evaluation, however, to assess its therapeutic potential fully. (+info)
Acute and long-term cost implications of coronary stenting.
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OBJECTIVES: We compared the acute and one year medical costs and outcomes of coronary stenting with those for balloon angioplasty (percutaneous transluminal coronary angioplasty) in contemporary clinical practice. BACKGROUND: While coronary stent implantation reduces the need for repeat revascularization, it has been associated with significantly higher acute costs compared with coronary angioplasty. METHODS: We studied patients treated at Duke University between September 1995 and June 1996 who received either coronary stent (n = 384) or coronary angioplasty (n = 159) and met eligibility criteria. Detailed cost data were collected initially and up to one year following the procedure. Our primary analyses compared six and 12 month cumulative costs for coronary angioplasty- and stent-treated cohorts. We also compared treatment costs after excluding nontarget vessel interventions; after limiting analysis to those without prior revascularization; and after risk-adjusting cumulative cost estimates. RESULTS: Baseline clinical characteristics were generally similar between the two treatment groups. The mean in-hospital cost for stent patients was $3,268 higher than for those receiving coronary angioplasty ($14,802 vs. $11,534, p < 0.001). However, stent patients were less likely to be rehospitalized (22% vs. 34%, p = 0.002) or to undergo repeat revascularization (9% vs. 26%, p = 0.001) than coronary angioplasty patients within six months of the procedure. As such, mean cumulative costs at 6 months ($19,598 vs. $19,820, p = 0.18) and one year ($22,140 vs. $22,571, p = 0.26) were similar for the two treatments. Adjusting for baseline predictors of cost and selectively examining target vessel revascularization, or those without prior coronary intervention yielded similar conclusions. CONCLUSIONS: In contemporary practice, coronary stenting provides equivalent or better one-year patient outcomes without increasing cumulative health care costs. (+info)
Lung perfusion studies after detachable coil occlusion of persistent arterial duct.
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OBJECTIVE: To evaluate relative lung perfusion following complete occlusion of persistent arterial duct with detachable Cook coils. METHODS: Ductal occlusion using detachable coils was performed in 35 patients (median age 3.9 years, range 0.5 to 16; 32 native ducts, three patients with previous devices). If the duct could be crossed with a 0.035 inch guidewire and a 4 F catheter after coil implantation, a further coil was implanted. Between one and seven coils were used (median two). RESULTS: Complete ductal occlusion was confirmed by echocardiography 24 hours after the procedure in all patients. Lung perfusion scans were performed three months after the procedure in 33 of 35 patients (two older patients with a single coil each did not attend). Decreased perfusion to the left lung (defined as < 40% of total lung flow) was observed in only one patient, who had previously had a 17 mm Rashkind umbrella implanted. There was no correlation between left lung perfusion and peak left pulmonary artery Doppler velocities (r = 0.27 and p = 0.125 for the entire group; r = 0.29 and p = 0.124 after excluding patients with previous devices). CONCLUSIONS: Coil occlusion is effective in achieving complete closure of the duct. An aggressive approach using multiple coils did not compromise perfusion to the left lung. (+info)
Fate of the stented arterial duct.
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BACKGROUND: The technical aspects of ductal stenting have been reported, but little is known of the fate of the duct after stent implantation. METHODS AND RESULTS: Nineteen patients underwent stent implantation to maintain ductal patency. Eight had hypoplastic left heart (HLH) syndrome, 10 had pulmonary atresia, and 1 had tricuspid atresia. Median survival with HLH was 57 (12 to 907) days. Stent implantation was successful in all cases of HLH, but there were no long-term survivors. Two well-palliated infants died at transplantation. Median survival with duct-dependent pulmonary flow was 183 (0 to 1687) days, with 3 patients well at latest follow-up (56, 55, and 9 months, respectively). There were 2 operative deaths due to ductal spasm and 4 late deaths, 1 due to duct thrombosis, 1 due to chronic lung disease, and 2 of unknown cause. Stent implantation failed in 4 of the 11 cases. Assessment of endothelialization was possible in 13 cases; the stent was partially covered in 3 and fully endothelialized in all 10 cases assessed >8 weeks after implantation. In patients stented for inadequate pulmonary flow, ductal intimal hyperplasia occurred by 9 months in all 3 survivors but responded to repeated dilation. CONCLUSIONS: Ductal stenting cannot be recommended. In patients with HLH, it provides only short-term palliation even when combined with pulmonary artery banding. With duct-dependent pulmonary blood flow, the procedure carries high risk, and duration of palliation is poor. In patients with bilateral ducts and absent central pulmonary arteries, good palliation may be achieved, but repeated angioplasty is necessary to counteract intimal hyperplasia. (+info)